Dear Neil and HIFA colleagues,
Thanks for your questions and comments, Neil. Let me take them in turn.
1. Evidence people avoiding health facilities helped to stop ebola outbreaks. Until recently, scholarly discussions have been clear on this issue. For example,
(a) In 2005, Susan Fisher-Hoch described DRC's (Zaire's) 1976 outbreak (p 129 in https://academic.oup.com/bmb/article/73-74/1/123/332389 ): “Most of the cases became infected in the hospital, and the local community, despite their poverty and lack of education, quickly figured this out and abandoned the hospital, effectively terminating the outbreak.” (See also WHO's account in: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2395567/ ).
(b) In 1999 CJ Peters described Kikwit’s 1995 outbreak (p sxiii in https://academic.oup.com/jid/article/179/Supplement_1/ix/879297): “Because of fear and of stigmatization, new cases were cared for at home and often in secrecy.... The importance of the medical care facility in amplifying the spread of Ebola virus is emphasized by the fact that only the hospitals in Kikwit and Mosango, DRC, had extensive transmission: 7% of patients left for small villages, and no transmission was noted there.”
2. Is WHO telling people about nosocomial ebola? Dr Ryan told WHO’s Executive Board. But WHO's weekly reports (Disease Outbreak News from WHO/Geneva and SITREPs from WHO/Africa at: https://www.who.int/ebola/situation-reports/drc-2018/en/) are not saying how many new cases are coming from health facilities. Similarly, DRC’s daily reports don't say how many cases are nosocomial. The world press is misled, writing stories about irrational and ignorant DRC residents with no recognition people are traumatized by nosocomial infections.
3. Yes! Health interventions should promote better infection and prevention and control (IPC)!
4. What about confusion? People facing unsafe healthcare are confused about when and where to go when they are sick or injured. Considering the risks they face, they have tough choices to make. We can help by offering crash courses and equipment to improve infection control, offering oral meds, telling people how to recognize safe injections (new syringe and needle, single dose vial), etc. But trying to manage public health messages to get people to think and do what experts want them to think and do is a slippery slope (cf: the Declaration of Lisbon).
Where to go from here? What happened in 1976 and 1995 is instructive, but situations change; cell phones, ebola vaccine, etc. Why are recent outbreaks so much worse than previous outbreaks? How to listen and learn from people traumatized by nosocomial infections? How to defuse anger for unintended accidents?
HIFA profile: David Gisselquist is an independent consultant in the United States and has a professional interest in nosocomial risks and transmission of HIV in Africa, agricultural development and agricultural inputs regulation, environment. Email address: david_gisselquist AT yahoo.com